STD Diagnosis in Primary Care: Essential Recommendations for Healthcare Providers

Sexual History and Physical Examination in STD Primary Care

Conducting a thorough sexual history and physical examination is the cornerstone of delivering high-quality STD care services within primary care settings. A comprehensive sexual history is crucial for risk assessment and should be integrated into initial, annual, or problem-focused visits concerning reproductive, genital, or urologic health, as well as STD-related symptoms or pregnancy planning. This assessment is equally relevant during HIV, PrEP, or acute care encounters. Utilizing the “five Ps” framework—Partners, Practices, Protection, Past STDs, and Pregnancy Prevention—ensures a detailed patient history. Resources like the CDC’s A Guide to Taking a Sexual History (https://www.cdc.gov/std/treatment/sexualhistory.pdf) offer valuable guidance.

The physical examination for STDs involves a careful inspection of the skin, pharynx, lymph nodes, anogenital region, and neurological system. This examination is particularly informative when patients present with STD-related symptoms, allowing healthcare providers to identify both apparent and subtle signs of infection.

For female patients, the anogenital examination includes a pelvic exam with three key components: visual inspection of the external genitalia, urethral opening, vaginal entrance, and perianal area; a speculum exam of the vagina and cervix; and a bimanual examination of the uterus, cervix, and adnexa. In cases of abnormal Pap smear results, colposcopy might be necessary for a closer examination of the cervix, vagina, and vulva, as recommended by the American Society for Colposcopy and Cervical Pathology (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801360). For male patients, the anogenital exam focuses on the external genitalia, including the penis, scrotum, scrotal contents, and perianal region. Anoscopy can be beneficial for individuals reporting rectal symptoms or a history of receptive anal intercourse.

Sexual history and physical examination recommendations for standard diagnosis in primary care are summarized in Box 1. Further details are available in Supplementary Appendix 1 (https://stacks.cdc.gov/view/cdc/82088).

Prevention Strategies in Primary STD Care

Preventing STDs and related conditions, including HIV, in primary care involves a multifaceted approach encompassing eight key strategies:

1. Condom Provision: Consistent condom use is a highly effective method for preventing STD transmission.
2. Hepatitis A Vaccination: Vaccination against Hepatitis A is recommended for at-risk populations.
3. Hepatitis B Vaccination: Routine Hepatitis B vaccination is crucial for STD prevention.
4. HPV Vaccination: Human Papillomavirus (HPV) vaccination is essential for preventing HPV-related cancers and genital warts.
5. Emergency Contraceptive Pills: Providing access to emergency contraception is part of comprehensive reproductive health care.
6. STD/HIV Prevention Counseling: Offering brief, moderate, or high-intensity counseling can empower patients to reduce their risk behaviors.
7. PrEP for HIV Prevention: Pre-exposure prophylaxis (PrEP) risk assessment, education, counseling, and provision or referral are vital for HIV prevention.
8. Nonoccupational Postexposure Prophylaxis (nPEP) of HIV: Providing nPEP risk assessment, education, counseling, and provision or referral to HIV care after potential exposure.

STD/HIV prevention counseling, incorporating behavioral counseling techniques, can facilitate positive behavior changes to minimize STD risk. Counseling intensity can range from brief sessions using motivational interviewing to more extended moderate- and high-intensity interventions. Contraceptive counseling is integral, enabling informed decisions about contraceptive methods. Linking patients to HIV medical care promptly after diagnosis is crucial for effective treatment and prevention efforts. Connecting patients with HIV care, family planning, and behavioral health services enhances viral suppression rates, reduces unintended pregnancies, and promotes long-term well-being. Refer to Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (87) and Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014 Summary for Clinical Providers (88) for detailed guidance.

Prevention recommendations for primary care are summarized in Box 2. Additional details are available in Supplementary Appendix 1 (https://stacks.cdc.gov/view/cdc/82088).

Screening Protocols for STDs in Primary Care

Routine screening for asymptomatic STDs is vital for early detection and prevention. Given that many STDs are asymptomatic, laboratory testing is the only definitive method for diagnosis. Screening tests are readily available for gonorrhea, chlamydia, syphilis, hepatitis B, hepatitis C, HIV, trichomoniasis, and cervical and anal cancer. Screening results are essential for identifying individuals at risk and initiating timely intervention. While routine anal cancer screening with anal cytology is not universally recommended, some centers perform it for high-risk populations, followed by high-resolution anoscopy for abnormal results. Colposcopy remains a key tool for cervical cancer screening.

Comprehensive screening recommendations for women, pregnant individuals, men, MSM, and persons with HIV are available at https://www.cdc.gov/std/treatment-guidelines/. STD screening recommendations for primary care are outlined in Box 3. Further information is in Supplementary Appendix 1 (https://stacks.cdc.gov/view/cdc/82088).

Partner Services for STD Management in Primary Care

Effective partner services are crucial for preventing STD reinfection and interrupting disease transmission. These services encompass various strategies to identify, test, and treat individuals exposed to STDs. Key components include:

1. Guidance on Partner Notification and Care: Providers should educate patients on the importance of informing their partners about STD exposure and the need for partner testing and treatment, even in the absence of symptoms.
2. Interactive Counseling for Partner Notification: This involves collaborative counseling to develop personalized partner notification plans, which may be carried out by the patient, provider, or health department.
3. Expedited Partner Therapy (EPT): EPT is recommended for partners of patients diagnosed with chlamydia or gonorrhea who are unlikely to seek timely medical care. EPT involves providing medication or prescriptions to the patient to deliver to their partner without a prior partner examination. EPT regulations vary by state, STD, age group, and sexual orientation; details are available at https://www.cdc.gov/std/ept/default.htm.
4. Health Department Disease Intervention Specialists (DIS): DIS professionals are vital for contact tracing, partner notification, and ensuring patient follow-up and treatment. Primary care settings are encouraged to collaborate with local health departments and DIS programs.

Partner services recommendations for primary care are detailed in Box 4. Additional information is available in Supplementary Appendix 1 (https://stacks.cdc.gov/view/cdc/82088).

Evaluation of STD-Related Conditions in Primary Care

Prompt evaluation of STD-related conditions is essential for accurate diagnosis and timely treatment to prevent complications and further transmission. Conditions warranting evaluation include:

• Genital ulcer disease: Potential causes include syphilis, HSV, chancroid, granuloma inguinale, and lymphogranuloma venereum (LGV).
• Male urethritis syndrome: Common sexually transmitted causes are gonorrhea, chlamydia, mycoplasma, trichomoniasis, and HSV.
• Vaginal discharge (vaginitis): Consider bacterial vaginosis, trichomoniasis, and candidiasis.
• Epididymitis, pharyngitis, cervicitis, and pelvic inflammatory disease (PID): Gonorrhea and chlamydia are frequent causes.
• Genital warts: Primarily caused by nononcogenic HPV types, but oncogenic types can occur.
• Proctitis: Causes include gonorrhea, LGV serovars of Chlamydia trachomatis, syphilis, and HSV.
• Ectoparasitic infections: Pediculosis pubis and scabies.
• Systemic or dermatologic conditions: Disseminated gonorrhea, neurosyphilis, ocular syphilis, condylomata lata, or palmar plantar syphilitic rash.

Patients presenting with symptoms suggestive of an STD etiology should undergo thorough evaluation.

Recommendations for evaluating STD-related conditions in primary care are summarized in Box 5. Further details are available in Supplementary Appendix 1 (https://stacks.cdc.gov/view/cdc/82088).

Laboratory Testing for STD Diagnosis in Primary Care Settings

Utilizing FDA-cleared laboratory tests is critical for accurate STD diagnosis in primary care. Point-of-care tests, performed on-site or through rapid-turnaround clinical laboratories, are ideal for providing same-visit results. Commercially available NAATs are FDA-cleared for detecting gonorrhea and chlamydia in genital specimens.

Laboratory testing serves both screening and diagnostic purposes. To enhance screening rates, primary care settings can implement structural interventions such as standing orders, express visits, specimen panels, and reflex testing. Sexual history and risk assessment guide the necessity of screening tests. For symptomatic patients, physical examinations and laboratory tests are essential for determining the cause and identifying any co-infections. Same-day diagnosis and treatment, particularly in STD specialty care settings, are crucial for improved patient and public health outcomes. Rapid results reduce treatment delays, complications, and onward transmission, and promote judicious antimicrobial use. STD specialty care settings should prioritize same-day diagnosis and treatment for symptomatic individuals and partners of those diagnosed with STIs. Laboratory recommendations for primary care are detailed in Box 6.

Treatment Protocols for STDs in Primary Care

In primary care and STD specialty settings that offer same-day treatment, therapy should not be delayed pending diagnostic test results. Prompt treatment minimizes complications and reduces community transmission. STD specialty care settings should provide on-site same-day treatment with a full course of appropriate medication, with the first dose administered in the clinic.

The CDC STD Guidelines (https://www.cdc.gov/std/treatment-guidelines/) and the STD Tx Guide app provide recommended treatment regimens. Wall charts and pocket guides summarizing guideline recommendations are also available online.

For primary care settings, on-site medication availability should ideally include recommended treatments for chlamydia and gonorrhea, first-line therapies for urethritis, cervicitis, PID, epididymitis, and proctitis, recommended syphilis treatments, emergency contraceptive pills, PrEP, nPEP, and provider-applied genital wart treatments. If on-site medication dispensing is not feasible, prescriptions should be readily available, with tracking systems to ensure prescription fulfillment. Collaboration with local health departments and community organizations can facilitate medication procurement, particularly injectable medications for syphilis treatment.

STD specialty care settings should maintain on-site availability of recommended medications for common STDs and related conditions, excluding treatments for bacterial vaginosis, yeast infections, UTIs, ectoparasitic infections, and patient-applied genital wart therapies. Medications for partners, as outlined in STD Guidelines, and EPT medications for gonorrhea and chlamydia should be on-site and managed according to state EPT laws. Alternative medications, provider-applied wart treatments, emergency contraception, and nPEP should also be available. Guidance on nPEP starter packs and linkage to care resources are available (https://stacks.cdc.gov/view/cdc/38856, https://stacks.cdc.gov/view/cdc/44065). Treatment recommendations for primary care are listed in Box 7.

Referral Guidelines for Complex STDs in Primary Care

The STD Guidelines outline conditions requiring referral to specialists with expertise in complex STD cases. Referrals should be made to clinicians specializing in infectious diseases (adult and pediatric), maternal-fetal medicine, allergy, ophthalmology, gastroenterology, colorectal surgery, urology, oncology, and other relevant fields. Services may be provided within multispecialty practices or hospital systems. Recommendations for specialist referral of complex STDs are detailed in Box 8.

This information aims to enhance STD diagnosis and management in primary care settings, improving patient outcomes and public health. For comprehensive guidance, consult the full CDC STD Treatment Guidelines.